Hajj health examination for pilgrims with asthma in Malaysia: An ethnographic study

Background Asthma was one of the top causes of hospitalization and unscheduled medical attendances due to acute exacerbations and its complications. In Malaysia, all pilgrims must undergo a mandatory health examination and certified fit to perform pilgrimage. We studied the current organisational and clinical routines of Hajj health examination in Malaysia with a focus on the delivery of care for pilgrims with asthma. Methods We conducted non-participant observation to obtain ethnographic understanding of Hajj health examination activities for 2019. Observations were guided by a checklist and recorded as notes that were analysed thematically. The study was conducted at 11 public (from each region in Malaysia, namely, North, South, East, West of Peninsular Malaysia, and Sabah and Sarawak of East Malaysia) and two private primary care clinics. Results We observed considerable variation in the implementation and practice of Hajj health examinations among the 11 public clinics but no marked variation among the private clinics. The short time span of between three to four months was inadequate for disease control measures and had put pressure on health care providers. They mostly viewed the Hajj health examination as merely a certification of fitness to perform the pilgrimage, though respiratory health assessment was often inadequate. The opportunity to optimise the health of pilgrims with asthma by providing the appropriate medications, asthma action plan and asthma education including the preventive measures was disregarded. The preliminary health screening, which aimed to optimise pilgrims’ health before the actual Hajj health examination was not appreciated by either pilgrims or health care providers. Conclusions There is great potential to reform the current system of Hajj health certification in order to optimise its potential benefits for pilgrims with asthma. A systematic approach to restructuring the delivery of Hajj health examination could address the time constraints, clinical competency of primary health care providers and resources limitations.

laysia was about 30 000 pilgrims per year. The Hajj Fund Board (HFB) (or its official corporate name Lembaga Tabung Haji), is an Islamic institution in Malaysia that manages fund deposited by Muslims and provides Hajj services for Malaysian pilgrims. It ensures a well-organised and safe Hajj operation to facilitate pilgrims obtaining a 'Mabroor' Hajj (Hajj that is accepted by God). Muslims who deposit money in HFB can register as prospective pilgrims and use their fund to perform the Hajj.
The pilgrimage is challenging even for those who are physically fit and able. It involves long walks of between 7-10 km per day for at least five days, performing compulsory rituals over rough terrain in extreme climates, some of which occur in confined spaces [3][4][5][6]. The cause of hospitalisation due to respiratory diseases during Hajj was estimated between 13.5% to 57.0% [4,6,7]. Cough, common cold, sore throat and shortness of breath are the commonest respiratory symptoms seen among pilgrims [8][9][10][11]. Malaysia has mandated all pilgrims to undergo the Hajj health examination and to be certified fit in order to perform Hajj. Hajj health examination is an activity whereby prospective pilgrims of the given year undergo clinical evaluation by primary care doctors with the aim of optimising pilgrims' physical and mental health to perform the rituals. This is organised by the HFB with assistance from the Ministry of Health, Malaysia (MOH). Pilgrims are given the option to undertake the examination at any selected public or private primary care clinics in their district. Public clinics are governed and fully funded by the government of Malaysia whilst private clinics are privately owned, funded and operated by a group of or an individual. Public clinics have been catering for the majority of the Hajj health examinations, which are normally conducted over a few days. Table 1 shows the organisation of the Hajj health certification in 2019 which outlines the process from the issuance of Hajj offer letter by HFB through departure for pilgrimage. The modules used for the training of doctors cover general physical examination, assessment of daily life activities, renal diseases and psychiatric assessment. HFB had also produced a guideline book for Hajj health examination [12] for health care providers' further references. The doctors consisted of doctors from public and private primary care clinics. A 'preliminary health screening' was instituted in 2019 to identify and resolve medical issues in advance of the Hajj health examination. It is not mandatory but is encouraged especially for pilgrims with chronic disease(s) and can be done by their regular doctors and/or clinics. The Hajj treatment record book (BRRJH) is a record of the pilgrims' medical history and examination, vaccination, and the status of fitness certification for Hajj. There are also sections for pilgrims' self-reported medical problems. This book is mandatory for use during the Hajj health examination and has to be carried by pilgrims throughout the pilgrimage. Theoretically the system should ensure that pilgrims with uncontrolled asthma achieve good control before embarking on the pilgrimage [12]. In neighbouring Indonesia, despite the compulsory Hajj health examination, 47% of partly controlled and 61% of uncontrolled pilgrims with asthma at embarkation had exacerbations during Hajj [13]. There is no study to date of its incidence among Malaysian pilgrims. However, a nationwide study across primary care centres in Malaysia found that based on GINA guidelines on asthma control, 41% had well-controlled, 38% partly controlled and 21% uncontrolled asthma [14]. Hence, we aimed to observe the implementation of Hajj health examination in Malaysia using asthma as an exemplar chronic disease to inform future strategies to improve care among pilgrims.

Study design
We conducted non-participant observation to obtain ethnographic understanding [15] of the organisational and clinical routines of the Hajj health examination for pilgrims with asthma in 2019. The study was conducted at 11 public and two private primary care clinics. Two clinics were selected from each region in Malaysia, namely, North, South, East, West of Peninsular Malaysia, and Sabah and Sarawak of East Malaysia. The clinics were selected to represent a range of organisational arrangements in primary care clinics including the location (urban and rural), infrastructure and facilities (large and small clinics) and the estimated number of pilgrims in the district. We obtained consent from the person in-charge of the Hajj health examination in the selected clinics.

Data collection
The observations were conducted for one whole day for clinics with many pilgrims and two days for clinics with small number of pilgrims. A checklist was used to facilitate the observation of the Hajj health examination processes [16]. The checklist was developed prior to observation through discussions among researchers and was adapted from domains described by Spradly, namely space, actors, activities, objects, actions, occasions, sequence, goals, and feelings [17]. Specific observations included the organisational preparation, appointments arrangement, clinical assessments and outcomes, continuity of care, vaccinations, management of pilgrims who were deemed unfit, access and communication of information to pilgrims.

Data analysis
Researchers' observation notes were documented and entered into Microsoft Word documents, which were transferred into the NVivo 12 software for coding. Two researchers independently coded the first observation notes based on the domain framework. Domain analysis involved systematic identification of components of the observed scene and possible subcategories. The observation notes were coded and categorised. Any discrepancies were discussed, and consensus reached to formulate the coding framework, which was then used to code the rest of the observation notes. Researcher AIB compared all the codes for accuracy and the codes were analysed thematically with the team. All researchers constantly reflected on the possible biases they had that could have influenced the interpretation during observation and analysis.

Patient and public involvement
Patients and public have helped in developing and shaping the research questions and design of this research.

Public primary care clinics
We observed variation in the organisation of the Hajj health examination at the 11 public primary care clinics. Two clinics catered pilgrims only from their clinic coverage area (decentralised) while the rest accepted pilgrims from the whole district (centralised). The number of pilgrims examined in each clinic ranged from 7 to 324 per day. There was no fee imposed on the pilgrims.
All appointments for the Hajj health examination had been arranged by the HFB and district health offices, and agreed upon by the clinics. Each clinic varied in their scheduling of examinations depending on the number of pilgrims allotted, the clinic workload and the availability of resources including the human resource, imaging, and laboratory facilities. Some conducted the Hajj examinations over the weekend while others conducted the examinations during weekdays amidst normal clinic activities. All but one clinic only examined pilgrims who had a scheduled appointment. The clinic in exception contacted pilgrims prior to examination date to confirm attendance; anyone who defaulted on the scheduled day were contacted and pilgrims who attended without appointment were also being seen.
All pilgrims were instructed by the HFB to bring all relevant medical documents and medication to facilitate the clinical assessment by doctors. The preliminary health screening form, if done and completed, was used as a guide for doctors. However, for a number of reasons this did not routinely happen. Some pilgrims did not receive the form while some who received, had not undergone this preliminary screening. Some pilgrims who had completed the screening did not bring the form on the examination day, so assessments or tests that had already been done had to be repeated. Some doctors were not aware of or did not check the preliminary screening form. The majority of the pilgrims at centralised clinics were not the clinics' regular patients and hence, their medical records were not available to the doctors on duty.
Various categories of health care personnel were involved in the Hajj health examination. Most of them were staff from the clinic itself while others were deployed from other clinics or the district health office. The ratio of doctors to pilgrims for the examinations ranged from 1:3 to 1:37. Table 2 and Table 3 summarise the overall findings of observations at the 11 public primary care clinics.
The organisation of the Hajj health examination varied depending on a combination of factors including the number of pilgrims, individual clinic needs and resources. When the examination was carried out over the weekend, most of the clinic areas were utilised and the process appeared to be more systematic and better coordinated. Two clinics undertook Hajj health examinations on Saturday and ran their out-patient service concurrently in separate clinic areas and both ran smoothly. Some clinics that ran the examination on weekdays amidst their usual outpatient clinics used separate registration counters and queues, or provided special counters for vital signs and anthropometric measurements and for checking completeness of documents. Some clinics created multiple 'stations' for pilgrims to follow in a sequence which seemed to streamline the flow. One clinic provided a checklist to help pilgrims understand the work flow. One clinic that did not separate the Hajj health examination from the usual out-patient care had long queues and appeared chaotic. Clinics that provided staggered appointments for the Hajj health examination appeared to have a manageable process, despite conducting it during working days. For six clinics where we timed the process, the time from registration until the completion of the whole process ranged between 1.5 to 6 hours.
Vital signs (body temperature, blood pressure, pulse rate) anthropometric measurements (weight, height and body mass index), Malaysian mental health screening (SSKM-20) scale and the Elderly Cognitive Assessment Questionnaire (ECAQ) and investigations (random blood glucose, haemoglobin and ABO blood group) had to be completed in the BRRJH. Electrocardiogram (ECG) and chest x-ray (CXR) were arranged if indicated as per HFB guideline requirements [12]. At one clinic, Pap smear and pelvic examinations were done on female pilgrims who were married and aged 40 years and above and had consented. At another clinic, MOH health status screening questionnaires were administered to all pilgrims before undergoing the Hajj health examination. These two screenings were not part of the Hajj health examination requirements but were carried out as opportunistic screening in these two clinics.
The duration of doctor's consultation timed at three clinics ranged between 15 to 30 minutes for each pilgrim. The assessments listed in the HFB checklist 12 included a review of medical history, vital signs, physical examination, and laboratory tests when necessary. Breast examination is mandatory for all female pilgrims. All the findings, diagnosis and management plan were recorded in the BRRJH. Most of the consultation rooms at the public primary care clinics lacked privacy; with between 2 and 4 doctors carrying out consultations in the same room, making physical examination and maintenance of confidentiality impossible. We observed many doctors did not conduct a proper physical examination. For example, for examination of the respiratory system, auscultations were done over the clothes and only over two points.
Spirometry and nomogram for PEFR measurements were not readily available in most clinics. Handheld spirometry was available at one clinic, but it was not utilised. Most clinics assessed peak expiratory flow rate (PEFR) on pilgrims with asthma. However, the measurements were not done consistently for all patients. Variation was observed in the assessment of peak flow; this included the category of staff who conducted the PEFR, the technique and the interpretation of the measurements. Some clinics had staff nurses and medical assistants performing the PEFR prior to doctors' consultations while others were conducted by the doctors as part of their consultations. Some clinics measured PEFR twice, some performed it on pilgrims without asthma, some used a paediatric peak flow meter for adults and some read the measured PEFR without referring to the nomogram [18].
The assessment of asthma control, medication adherence and inhaler techniques including spacer use or need were observed to be suboptimal. The interpretation of the PEFR readings did not seem to influence the doctor's management. There seemed to be hesitation among the doctors on the assessment, management, and fitness certification for pilgrims with uncontrolled asthma. They typically referred pilgrims with uncontrolled asthma to a family medicine specialist for further management and fitness certification rather than optimising asth-   were encouraged at private clinic PFM -peak flow meter, PEFR -peak expiratory flow rate, GINA -Global Initiative for Asthma, MDI -metered dose inhaler, COPD -chronic obstructive pulmonary disease Table 3. continued Table 4. Observations related to organisation of Hajj health examination in private primary care clinics (n = 2) General practitioner clinic 1

General practitioner clinic 2
Screening period / day Any day during screening period. By appointment or walk-in Any day during screening period. By appointment or walk-in

Not applicable
Not applicable

Conducted in treatment room
Combined with outpatient pool Locum doctor runs the usual clinic

Process
As part of normal clinic operation As part of normal clinic operation

Preventive measures for attacks
General advice (to bring medications, check expiry, diet control and exercise) General advice like prevent dehydration Optional vaccination available and encouraged (influenza, pneumococcal) PFM -peak flow meter, PEFR -peak expiratory flow rate, MDI -metered dose inhaler ma treatment themselves. Pilgrims were mainly given general advice such as ensuring sufficient, non-expired medications including inhalers, to wear a mask to protect from dust and to stay hydrated. There was little/no individualised asthma education on preventive measures or provision of asthma action plans for the pilgrimage. Almost all patients were encouraged to get the optional influenza and pneumococcal vaccinations from private centres if they were willing to pay.

Private primary care clinics
We observed two and three pilgrims who attended two private general practitioner (GP) clinics respectively for Hajj health examination. Pilgrims were encouraged to make appointments to ensure the availability of doctor who was eligible to certify the Hajj health examinations. Laboratory investigations were outsourced to private laboratories. The optional influenza and pneumococcal vaccines were readily available at both clinics. All pilgrims were charged a fee. With the very small number of pilgrims, the process of Hajj health examination at both clinics was manageable. Only one pilgrim with asthma attended one of the clinics. For this pilgrim, a thorough assessment of control and adequate respiratory examination were conducted. Table 4 and Table 5 summarise the overall finding of observations at the two private primary care clinics.

Outcomes of the Hajj health examination
There were four outcomes for pilgrims after the Hajj health examination: (i) passed and certified fit for Hajj, (ii) identified to have uncontrolled medical problem and referred for treatment optimisation followed by re-evaluation (iii) identified to have serious medical problem and referred to specialised disciplines at tertiary centres followed by re-evaluation, or (iv) failed and certified physically unfit for Hajj. All doctors performing the Hajj health examination were required to fill in a summary form in the BRRJH, stating the pilgrim's final status of fitness certification for submission to the HFB database system.

DISCUSSION
We observed considerable variation in the organisation of Hajj health examination among public primary care clinics. The implementation of centralised Hajj health examination posed a challenge to the health care providers in balancing the need for appropriate clinical evaluation and disease control, and the pressure for the Hajj certification within a limited time frame. As a result, Hajj health examination was mostly viewed as merely a ticket to certify fitness for pilgrimage rather than an opportu-nity to optimise chronic disease management including asthma. Poor physical examination of the respiratory system and suboptimal long-term management of chronic disease were two consistent observations related to asthma care and concerning aspects of the process that require further attention.
Two main disadvantages of the organisation of centralised clinic for Hajj health examination were time constraint due to heavy workload and unavailable medical records of pilgrims from external clinics. These compromised the comprehensiveness of clinical evaluation and disease management, provision of relevant health education including preventive measures and delayed the certification process for more complex cases. Time constraint is a recognised stress factor at work that can result in adverse consequences for primary care doctors and their patients' care [19]. As the preliminary health assessment was not mandatory and was not often done, it was of concern that some pilgrims did not declare their known health issues. Moreover, unfamiliarity of the pilgrims to external doctors who were pooled to work at the centralised clinics possibly affected the establishment of appropriate doctor-patient relationship and hindered the delivery of health education and disrupted the continuity of care. Doctor-patient relationship is a powerful component of consultation and can alter various health related outcomes for patients. New patients, time-constraints and the health care setting are some identified factors that can adversely affect the doctor-patient relationship [20].
Despite time constraint being a contributing factor, the suboptimal assessment and management of asthma by the doctors, also significantly reflects the level of clinical competencies among primary care doctors, in particular the assessment of control, evaluation and management of uncontrolled asthma and provision of asthma education especially the asthma action plan. Many doctors did not seem to assess and manage the disease based on any guideline recommendation such as Malaysian Clinical Practice Guidelines (CPG) [18] or the GINA [21] recommendations. This is consistent with a study that found the implementation of asthma CPG as suboptimal in primary care [22]. Heavy workload and inadequate training were two important barriers to low adherence by primary care doctors to the guidelines [23]. Clinical pathway and supporting educational materials can be created and used to translate the evidence-based guidelines into succinct algorithms and facilitate the asthma care by primary care doctors [24,25]. Effective asthma self-management requires a comprehensive approach comprising of patients' education and resources, professional skills and motivation and organisation priorities and routines [25].
The implementation of the Hajj health examination can be carried out more systematically if it is directed towards clearer objectives. The two main objectives should be (i) final certification of pilgrim's health status and (ii) checking of the relevant documents. The HFB can make the Hajj preliminary health screening compulsory on receipt of the Hajj offer letter to ensure pilgrims' health is assessed by their regular doctors or clinics in advance to the Hajj health examination. For asthma, this would provide ample time for optimisation of the pilgrims' asthma control through adequate clinical evaluation including investigation and referral if necessary and opportunity to provide health education. Hence, the main role of doctors on duty for the Hajj health examination would be to consolidate the medical information prepared beforehand and establish the final status of fitness certification. For pilgrims with no known medical problem, the preliminary health screening is an avenue to detect occult disease and prompt earlier investigation, treatment, and disease stabilization. Neighbour country Indonesia uses an Integrated Hajj Computerized System (SISKOHAT), whereby pilgrims' health information system is one of the integrated components [26]. It allows a longer and adequate time frame for pilgrims' health optimisation and enables entry and update of pilgrims' health information by all health services accessed by the pilgrims at any point of time. It involves three steps: screening at primary health care, disease control taking place in hospitals and final certification of fitness for Hajj. In step 1, their policy established a mandatory health screening and health coaching programs before the Hajj medical examination, as an effort to prepare fit and healthy pilgrims for Hajj. These programs comprise of a preliminary medical checkup, health promotion and prevention and physical exercise activities besides the Hajj rituals training [27,28].
For pilgrims, HFB could initiate and promote the importance of being fit and healthy for pilgrimage, by sending health reminders and guides to the pilgrims in the year before their Hajj scheduled year. This would hopefully trigger early awareness and efforts to achieve adequate disease control (including asthma) and sustain optimum health status to perform pilgrimage. Printed or electronic educational resources can provide quick access to information related to asthma. Supporting materials like videos or links to YouTube channels relevant to health and disease care can be provided along with the reminder [29].
This study is the first to observe the implementation and practice of the Hajj health examination in Malaysia with a focus on the delivery of care for pilgrims with asthma. It captured the real practice of Hajj health examination across a range of primary care organisations including the location, infrastructure and facilities, and the number of pilgrims. However, our selected clinics might not have included all organisational variations, and the days we observed might not have been typical while the number of private general practitioner was too small to draw definitive conclusions on the practice of Hajj health examination at private primary care clinics. Moreover, participation in research and the presence of an observer might have affected the health care providers' behaviour and clinical conduct, especially of asthma care. Studies on the views of pilgrims and various stakeholders involved in the Hajj health examination process should provide more supportive data. Nevertheless, the findings may provide performance data for analysis and basis for potential avenues to improvement by the HFB and MOH. Besides asthma, it could also be extended to other chronic diseases to influence future strategies to improve care among pilgrims.

CONCLUSION
As a conclusion, there is great potential to reform the Hajj health certification process in Malaysia and to improve the provision of asthma care in primary health care. Strategies to restructuring the delivery of Hajj health examination could address time constraint, clinical competency of primary health care providers and resources limitations. This is to reduce the risks posed from asthma, and by extension the other chronic diseases, not only during pilgrimage but also on the impact to the long-term health.